1073617593 NPI number — BAYLOR UNIV HEALTH CENTER PHARMACY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073617593 NPI number — BAYLOR UNIV HEALTH CENTER PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYLOR UNIV HEALTH CENTER PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073617593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 SPEIGHT AVE
Provider Second Line Business Mailing Address:
STE 214
Provider Business Mailing Address City Name:
WACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76706-1507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-710-4268
Provider Business Mailing Address Fax Number:
254-710-3620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 SPEIGHT AVE
Provider Second Line Business Practice Location Address:
STE 214
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76706-1507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-710-4991
Provider Business Practice Location Address Fax Number:
254-710-3620
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KILGORE
Authorized Official First Name:
PAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC
Authorized Official Telephone Number:
254-710-4268

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  01423 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4543535 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".




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